Staff Medical Release and Consent

2022 YLC Staff Medical Release and Consent Form

I understand that every effort will be made by NAD Youth Leadership Camp officials to reach my parents or guardians in case of emergency or when outside medical care is needed. In the event that my parents or guardians cannot be reached in an emergency, I hereby give permission to authorize NAD Youth Leadership Camp officials to order X-rays, routine tests, and any other treatment as may be deemed necessary for me named below.
Name * Required
First Middle Last
Email * Required
And I hereby give permission to the physician selected by the camp officials to hospitalize, secure proper treatment for, and to order injection and/or anesthesia and/or surgery for me as named on the above line. I hereby give permission for camp officials to administer medications as deemed necessary to me. This includes medications sent with me, or non-prescription medications available at the camp or prescriptions ordered by a physician during the camp session. I understand that any medical expenses will be billed directly to my insurance carrier. The hospital and/or medical facility will be instructed to forward the bill to me if my insurance carrier does not follow through with the payment after a period of time. Further, I hereby release the National Association of the Deaf and its officers, directors, employees, agents, and subcontractors, from any and all liability for bodily injury, or costs of medical treatment thereof, or injury incurred as a result of the administration of emergency treatment. This form may be photocopied for use outside of the camp, for the purposes described herein. The camp will charge me for any prescriptions and/or medications ordered by the physician that we do not stock. This includes dental-related concerns.

The authorization and consent shall be valid from June 20 - July 26, 2022.
eSignature * Required
SSN * Required
Birthdate - must be mm/dd/yyyy format * Required
MM slash DD slash YYYY
Age * Required
Gender * Required
Primary Emergency Notification
Name * Required
First Last
Relationship to staff member * Required
Address * Required
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Daytime phone number * Required
Which method is the daytime number? * Required
Evening phone number * Required
Which method is the evening number? * Required
Email * Required
Alternate Emergency Notification
Name * Required
First Last
Relationship to staff member * Required
Address * Required
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Daytime phone number * Required
Which method is the daytime number? * Required
Evening phone number * Required
Which method is the evening number? * Required
Email * Required
Health Insurance Information
Note: all staff members are required to have health insurance. If you do not have health insurance, please contact [email protected]
Insurance Company: * Required
Name of the Insured * Required
First Last
Staff Member's relationship to the Insured * Required
Policy ID Number * Required
Group Name/Number * Required
Family Physician * Required
First Last
Address * Required
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone * Required
Emergency phone number * Required
Health Insurance Card (upload front and back) * Required
Drop files here or

Accepted file types: pdf, doc, docx, jpg, gif, png, jpeg, Max. file size: 300 MB.
Important Note:
The staff’s doctor must complete the Health Form. Be sure that the exam is done between July 26, 2021 - June 20, 2022. Exams done before July 26, 2021 will not be accepted.

All medications brought to camp by staff must be in containers that are clearly labeled with the name of staff, the name of the medication, the dosage, the frequency of administration and the route of administration. All medication prescribed by a physician must, in addition, be labeled with the name of the prescribing physician, the prescription number, date prescribed, possible adverse reactions, the specific conditions when contact should be made with the physician and other special instructions as needed.
COVID-19 Vaccination

To safeguard the health and safety of everyone in our camp program, we are requiring all campers to be fully vaccinated against the COVID-19 virus. Please contact [email protected] if you are unable to get vaccinated.
COVID-19 Vaccination Card
Please attach a photocopy of your COVID-19 vaccination. If you do not have it available, please email [email protected] a photocopy of your vaccination card once you've received your vaccination.
Drop files here or

Accepted file types: pdf, doc, docx, jpg, gif, png, jpeg, Max. file size: 300 MB.